<%@ Page Language="C#" MasterPageFile="~/FacilityHeaderFooter.master" AutoEventWireup="true" CodeFile="frmHome_Visit.aspx.cs" Inherits="Scheduler_frmHome_Visit" Title="Untitled Page" %>
<asp:Content ID="Content1" ContentPlaceHolderID="facilityheaderfooter" Runat="Server">
<div style="padding-top: 140px;">
<%--<H1 class=margin>Home Visit Form</H1>
--%><DIV class="border center formbg"><!-- DAL: using tables for form layout. Note that there are classes on labels and td. For custom fields, just use the 2 column layout, if there is an uneven number of cells, set last cell colspan="2" and align="center". Probably should talk through this -->
<TABLE cellSpacing=6 cellPadding=0 width="100%" border=0>
  <TBODY>
  <%--<TR>
    <TD class="formcenter" colSpan=2>
    <LABEL class=patientInfo>Patient Name:</LABEL>
    <asp:Label ID="lblpatientname" runat="server" Text="Mary Longlastname"></asp:Label>
        <LABEL class=patientInfo>Satellite #:</LABEL>
    <asp:Label ID="lblsateliteid" runat="server" Text="99"></asp:Label>
    <LABEL class=patientInfo>Patient Enrollment #:</LABEL> 
    <asp:Label ID="lblpatientenrolment" runat="server" Text="444545"></asp:Label>
    <LABEL class=patientInfo>Existing Hosp/Clinic #:</LABEL>
    <asp:Label ID="lblexisclinicid" runat="server" Text="12345678-444444-596A"></asp:Label></TD>
  </TR>--%>
  
      <TR> 
                  <TD class="form" width="50%">
                      <LABEL 
      class="right50">CHW/CHV/Nurse Team:</LABEL>
                      <input 
      name=CHW id=txtCHW runat="server" >
                  </TD>
               <TD class="form" valign=middle>
                      <LABEL class="required right35">*Home Visit Start Date:</LABEL>
                      <INPUT id=StartDate maxLength=10 size=10 
      name=StartDate runat="server" >
                      <IMG 
      onclick="w_displayDatePicker('<%=StartDate.ClientID%>');" height=22 
      alt="Date Helper" hspace=3 
      src="../images/cal_icon.gif" 
      width=22 border=0><SPAN class=smallerlabel>(DD/MM/YYYY)</SPAN>
      </TD>
                </TR>
                <TR> 
               
                    <TD class="form">
                      <LABEL 
      class="right50">Alternative CHW/CHV/Nurse Team:</LABEL>
                      <input 
      name=guardian2 id=txtguardian2 runat="server" >
                  </TD>
                
                  
                     
                  <TD class="form"> 
                      <LABEL class=margin10>Number of Weeks:</LABEL>
                      <INPUT id=txtphysRR23 maxLength=5 size=5 
      name=physRR2 runat="server" />
      <LABEL class=margin20>Number of Visits per Week:</LABEL>
                      <INPUT id=Text1 maxLength=5 size=5 
      name=physRR2 runat="server" />
                       </TD>
                       </TR>
           
           
                <TR> 
                
                
                  <TD class="form" colSpan=2>  
                  
                  
                 <label class=right20>Visits by Week: &nbsp;</label>
                 <LABEL>Week 1:</LABEL> 
                        <select name="VisitsPerWeek" id="VisitsPerWeek"  runat="server" >
                          <option value="">-Select-</option>
                          <option value="1">1 day</option>
                          <option value="2">2 days</option>
                          <option value="3">3 days</option>
                          <option value="4">4 days</option>
                          <option value="5">5 days</option>
                          <option value="6">6 days</option>
                          <option value="7">7 days</option>
                        </select>
                        <LABEL class=margin10>Week 2:</LABEL>
                        <select name="VisitsPerWeek" id="Select1" runat="server" >
                          <option value="">-Select-</option>
                          <option value="1">1 day</option>
                          <option value="2">2 days</option>
                          <option value="3">3 days</option>
                          <option value="4">4 days</option>
                          <option value="5">5 days</option>
                          <option value="6">6 days</option>
                          <option value="7">7 days</option>
                        </select>
                        <LABEL class=margin10>Week 3:</LABEL>
                        <select name="VisitsPerWeek" id="Select2" >
                          <option value="">-Select-</option>
                          <option value="1">1 day</option>
                          <option value="2">2 days</option>
                          <option value="3">3 days</option>
                          <option value="4">4 days</option>
                          <option value="5">5 days</option>
                          <option value="6">6 days</option>
                          <option value="7">7 days</option>
                        </select>
                        <LABEL class=margin10>Week 4:</LABEL>
                        <select name="VisitsPerWeek" id="Select3" >
                          <option value="">-Select-</option>
                          <option value="1">1 day</option>
                          <option value="2">2 days</option>
                          <option value="3">3 days</option>
                          <option value="4">4 days</option>
                          <option value="5">5 days</option>
                          <option value="6">6 days</option>
                          <option value="7">7 days</option>
                        </select>
                    </TD></TR>
    
    
 
  <TR>
    <TD class="pad5 center" colSpan=2><BR><INPUT type=submit value="Save" name=submit id="btnsave" runat="server"> 
    <INPUT type=submit value=" Data Quality Check " name=complete id="btncomplete" runat="server"> 
    <br />
</TD></TR></TBODY></TABLE></DIV>
</div>

</asp:Content>

